ON PURULENT OPHTHALMIA AND ITS TREAT- MENT BY HOT-WATER APPLICATIONS BY ALBERT G. HEYL, M.D. PHILADELPHIA [Reprinted from the Archives of Ophthalmology, Vol. xv., No. 3, 1886] ON PURULENT OPHTHALMIA AND ITS TREAT- MENT BY HOT-WATER APPLICATIONS * By ALBERT G. HEYL, M.D., of Philadelphia. THE bacterial origin of many diseases is no longer a speculation, but a substantial fact. At the present time the science of the subject is far in advance of the clini- cal applications ; and yet the latter are of profound practical importance to every physician. Diseases like croup, phthisis, cholera, etc., will probably only be successfully treated from the standpoint of the mycologist, and it becomes therefore a matter of great practical moment to understand the phe- nomena which follow the settling of micro-organisms in living tissue and the effect of treatment in modifying the same. The conjunctiva offers the best surface in the body for such studies, and I might very profitably spend the time allotted to me in detailing the clinical phenomena which occur in connection with different forms of bacterial infection of this membrane. I propose, however, to direct attention to the effect of hot-water applications in ONE form of bacterial conjunctival infection, viz., that commonly known as purulent ophthalmia. It will be necessary to make some general statements with reference to recent re- searches in regard to this disease. Purulent ophthalmia is a disease of the conjunctiva characterized by great swelling of the lids, profuse puru- lent discharge, with a marked tendency to corneal ulceration. As it commonly occurs in newly born children, it has re- ceived the name of ophthalmia neonatorum ; again, it occurs * Read before the State Medical Society of Pennsylvania, June 3, 1886. Reprinted from the Archives of Ophthalmology, Vol. xv., No. 3, 1886. 312 Albert G. Heyl. in adults as the results of infection with gonorrhoeal matter, and hence the name gonorrhoeal ophthalmia. They are essentially the same disorder, caused by the same germ, and ought to be discussed under the same head. Mycologi- cal research seems to indicate that there is a form of virulent conjunctivitis in the newly born child which may be con- founded with the bacterial conjunctivitis. Perhaps we may be able clinically to differentiate the two. In this paper I am discussing the bacterial form. The disease is very destructive of sight. Statistics of blind asylums show a percentage variously stated of from thirteen to forty-six per cent, of inmates rendered blind from this disease, and these statistics do not take into account a large number of cases of monocular blindness which have not been obliged to seek the refuge of the asylum. The disease is therefore of great importance to the community at large and also to physicians in general practice, for these cases almost always necessarily fall into the hands of the general practitioner at an initial period of the disease. The interest in this disease has been greatly enhanced since Neisser (1879) discovered the germ which is its cause. Various observers having confirmed the results of Neisser's researches, this " gonococcus " to-day is perhaps one of the best understood of the micro-organisms that infest the human body.1 Let us consider a few points brought out by these researches : 1. It attacks the cylindrical epithelium of the conjunctiva, leaving the pavement epithelium untouched. Two years ago 2 I called attention to the physiological distinction between two sections of the conjunctiva, viz., the palpebral and sclero-corneal sections. The former I believe to be a lubri- cating organ, the latter an essential part of the apparatus of sight-i. e., without it the function of sight could not be properly performed. Now the interesting point in this connection is that the palpebral conjunctiva has cylindrical epithelium, while the sclero-corneal section has pavement epithelium. Recalling now the fact already stated, that the 1 Vide the monograph on the " Gonococcus Neisser," by Dr. Ernst Bumm, published by J. F. Bergmann, Wiesbaden. 2 " Transactions of the Medical Society of the State of Pennsylvania," 1884. Purulent Ophthalmia. 313 gonococcus attacks the cylindrical epithelium, we come to^his conclusion, viz., that the palpebral conjunctiva is the culture- ground of the coccus. The rule with regard to applications of nitrate of silver in this disease, viz., that they are to be applied only to the palpebral conjunctiva, is now perfectly explained. It is because we then attack the position in which the coccus finds the condition necessary for its growth. 2. The growth of the coccus depends on the age of the epi- thelial cells. The process seems to be essentially this: The coccus finds its way into the conjunctival sac, lays hold of the cylindrical epithelium, disintegrates it, and then finds its way into the subepithelial tissue; at this stage it ceases to grow ; by and by the destroyed epithelia have been replaced by new cells, and as soon as this happens, the propagation begins again, until the new cells have been destroyed ; and thus the process goes on. In other words, cells in the early stage of development furnish no proper nutriment for the coccus. Again, we find an explanation of a therapeutic procedure developed by the great clinical genius of Von Graefe, viz., that following the destruction of the superficial layer of epithelial cells a cessation of the virulence of the inflammation is observed; presently with the regeneration of the epithelium the inflammatory symp- toms increase in violence. If, previous to this latter stage, fresh applications of the nitrate be made, the imflammatorj^ relapse can be prevented. In the light of the mycological researches the reason of this is evident, viz., by the applica- tions of the nitrate we are keeping the cells of the tissue in a young state unfavorable for the growth of the coccus; it ceases to grow, dies, and the disease is cured. 3. The vitality of the cell affects the coccus. By vitality is meant that property of the cell which is concerned in the increase in bulk or area of tissue. In the young child this vitality is such that the frame increases in size, the cell multiplication taking place to such an extent that the organs grow. In the adult the organs retain their bulk, disintegration and repair of tissue being about in equilibrium. Now, the essential principle involved in this 314 Albert G. Heyl. is the vitality of the cell, and when this is weak we have a condition relatively favorable to the growth of the coccus, and vice versa. I deduce this from the clinical fact that gonorrhoeal conjunctivitis of the adult is a much more vir- rulent disease than blennorrhcea neonatorum. Perhaps it might have been deduced from the preceding point, viz., that relating to the age of the cell, but a young cell is not necessarily highly vitalized. 4. The coccus is not merely confined to the palpebral conjunc- tiva, but finds its way into the lymph circulation, and is swept into regions where it finds no sustenance, but, accumulating in masses, blocks up the nutrient channels. I believe the corneal ulceration is the result of such blocking. The cocci are carried into the connective-tissue spaces underneath the scleral conjunctiva, lifting it up into mound-like promi- nences. These mound-like prominences vary in extent ; not uncommonly they completely girdle the cornea. Probably the swollen retrotarsal fold is caused to a great extent in this way. The cocci are transported into another locality, viz., into the substantia propria of the cornea. Here is an unyielding tissue. The cocci simply block up the nutrient channels, necrosis of the involved area occurs, resulting in the deep, well-defined ulcer of this disease. According to the foregoing remarks, two distinct objects are to be kept in view in the treatment: 1. To stop the growth of the coccus. 2. To prevent the coccus from accu- mulating in the cornea, where it does harm, not by its directly ravaging the tissue, but by blocking the nutrient channels. The disease being caused by bacterial infection, the question naturally arises : Can it not be successfully treated by dropping some antiseptic into the conjunctival sac, and thus destroying the gonococcus ? I know of no such sub- stance. It is, in my judgment, an error to suppose that, because a given substance will sterilize a flask swarming with gonococci, therefore, the same gonococcus will be destroyed by this agent when growing in the conjunctival sac. The conditions of growth may be altogether different in the two cases. The truth is that the antiseptic treat- Puruleut Ophthalmia. 315 ment of living tissue is a very much more complicated process than is commonly supposed. The treatment by nitrate of silver has already been alluded to. Its essential is that the cells of the palpebral conjunctiva are kept in a young and probably highly vitalized condition, and there- fore the coccus, finding no sustenance, dies, and the disease is cured. Properly applied, it is the best-known treatment for this disease, so far as the palpebral conjunctiva is con- cerned. Unfortunately, it requires a skilled hand to apply it. I have been led, therefore, to use also in this disease hot-water applications, which can be readily applied by the attendants of the patient. Hot-water applications are an old remedy in ophthalmic surgery ; they have been used by others in this disease, but the rationale of their action is perhaps unknown. The action of heat upon living tissue may be studied from two aspects: i. Its directaction upon the cells of the part. This therapeutically belongs to the theory of the actual cautery. 2. Its indirect action ; this affects the cells of the tissue through the circulating fluids ; the latter being warmed and coming in contact with the tissue cells, induces increased activity and cell prolifera- tion. This is shown microscopically by the effect of heat upon the living cell, likewise clinically by the fact that by proper application of heat to the eyelids the cornea can be vascularized. The use then of heat in certain forms of bacterial infec- tion will be understood, viz., that by so acting indirectly upon the cells of the part, the tissues are placed in a condition unfavorable for the growth of the bacterium. Oertel's1 experience in the use of hot steam applied to diphtheritic deposits exemplifies this. Oertel's observation, in brief, is as follows: In a certain infected tissue we may observe the diphtheritic deposits shading imperceptibly into the sur- rounding tissue. If now hot steam be applied to this tissue, it will be noticed that the deposits become distinctly cir- cumscribed ; along with this, new deposits seem to form, and we might suppose that the deposits were increased in num- ber by the application. This, however, is a mistake ; it is 1 Ziemssen's Encyclopedia, vol. i. 316 Albert G. Heyl. simply owing to the fact that the whole tissue has been in- filtrated, and the heat is simply circumscribing different foci, many of which previously were unrecognizable. The pro- cess goes on until finally the central masses of infiltration are thrown off, a layer of pus cells being formed at the plane of separation. Oertel says the heat induces suppura- tion, and thus the pseudo-membrane is cast off. To my mind the explanation is not sufficiently explicit or accurate. It looks to me as if the heat acted on the tissue in such a way that the bacterium found no proper sustenance and died. In many places, however, the tissue cells had been so affected by the parasite that restoration was impossible ; these constituted the sloughs. At the plane of union of the slough and underlying tissue the cells were in a par- tially normal condition, and yet incapable of restoration. These were mainly concerned in the formation of pus. Underneath these again were cells which, under the influ- ence of heat, maintained their integrity. We are doing with these hot applications essentially the same thing as with nitrate of silver-putting the cells in such a condition that the coccus ceases to live. Practically, under their use the dwelling subsides, the dis- charge becomes less, and the disease is checked. There is, moreover, one phase of this disease to which the hot appli- cations are peculiarly adapted, viz., when the coccus ac- cumulations form underneath the scleral conjunctiva, or in the corneal tissue itself. In this condition the nitrate can only act by preventing further coccus propagation, and, per- haps, in a measure, through its action on the palpebral cells, by increasing to a certain extent the force and velocity of the lymph stream, thus tending to disperse the coccus accumula- tions. The hot applications are vastly more efficacious for this purpose, and it is my own practice, when the corneal cloud has formed, to suspend the nitrate and rely upon the hot applications. In this way I have seen corneal opacities, on the verge of breaking down in ulceration, dispersed. It is possible that, even at this stage, the nitrate of silver, if carefully neutralized with a solution of salt, might be used with advantage. Purulent Ophthalmia. 317 The point, then, which I wish prominently to bring forward is, that in hot water we possess a remedy that requires no special skill in its application, acts in regard to the palpebral conjunctiva on the same principle as the nitrate of silver, and is of especial value when the cornea is involved. There is one thing to be said with reference to the appli- cation of heat in gonorrhoeal ophthalmia of the adult. In these cases I have missed the rapid yielding to the treat- ment which is noticed in the infant. The disease is of a very much more violent grade in the adult, probably for the reason already stated. I have employed the hot water very actively and persistently without noticing immediate relief from it. The disease finally subsided, but by no means rapidly. I believe, however, that the best treatment at present for this virulent form is the repeated applica- tions of weak solutions of nitrate of silver, carefully neutral- ized, say, every three hours, with constant applications of hot water. The method of applying the hot water is as follows: A basinful of hot water, as hot as the hand can comfortably bear it, is placed by the patient, a handful of absorbent cotton dipped into it and applied to the closed eyelids; as fast as it cools, which may be in a quarter of a minute, it is reapplied. The applications are kept up for five minutes at a time ; in infants, three times daily is sufficiently often for these applications. In more virulent cases they may be used oftener. putnam's sons print